Provider Demographics
NPI:1548690837
Name:LOSTRACCO, MARK (DPT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LOSTRACCO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 S IDAHO RD
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85119-6496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1075 S IDAHO RD
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119-6496
Practice Address - Country:US
Practice Address - Phone:480-983-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11376225100000X
TX1237856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist